This project will use the techniques of epidemiology and quality improvement to study the management of patients undergoing coronary artery bypass graft surgery in Northern New England. The broad objective is to identify areas of opportunity for diminishing the rate of different types of strokes for this patient population. Specific aims are to demonstrate how improved surgical technique, awareness of patient risk factors, and change in process of care may diminish the rate of different types of strokes. The project design is based on local efforts aimed at improving the mortality associated with CABG surgery. The design would utilize a three-pronged approach. First, the Northern New England Cardiovascular Disease Study Group (NNE) would utilize a preoperative clinical risk prediction score to develop specific clinical interventions aimed at diminishing the occurrence of strokes consequent to surgery. Second, multidisciplinary teams from each center would be used to develop, support and implement these interventions. Last, the NNE would assess the effect of these interventions by monitoring the rates of stroke and compare these rates to historical regional norms. This focused implementation of the techniques of modern continuous quality improvement to the problem of postoperative stroke is a logical extension of our work and builds on thirteen years of cooperation in this region. It will contribute to the science of cardiothoracic surgery by moving past measurement and toward reengineering of clinical care and may also provide a reproducible model for the improvement of medical and surgical services.